UCSD flips script on telemedicine practice

Pilot project brings in extra doc when ER gets busy

Dr. David Guss, chair of the Department of Emergency Medicine at UC San Diego Health System, is principal investigator of a new pilot program designed to increase emergency room staffing using telemedicine. In the background is a telemedicine cart used by the new program.
Paul Sisson

Dr. David Guss, chair of the Department of Emergency Medicine at UC San Diego Health System, is principal investigator of a new pilot program designed to increase emergency room staffing using telemedicine. In the background is a telemedicine cart used by the new program.

Today, telemedicine usually involves a doctor in his office examining a patient in a rural community, military installation or other far-flung locale. But a pilot program at UC San Diego Medical Center aims to reverse that relationship, using computers and video cameras to bring an extra doctor to the bedside when things get busy.

Dr. David Guss, the program’s principal investigator and the university’s outgoing chair of emergency medicine, said the idea is to add extra doctors just for when they are needed.

“It gives us the ability to take you out of the waiting room, do an initial exam, order tests and X-rays and send you back to the waiting room,” Guss said. “All of this time that you would have been sitting in the waiting room with nothing happening, now your workup’s going to be underway.”

The program has been going since January, and the doctor said about 120 patients, all of whom gave their consent before being examined, have been seen so far. Preliminary data for the first 60 patients shows a 40 percent decrease in length of stay for those patients who start their visit electronically, compared with those who just wait the traditional way, the doctor said.

This new way of seeing patients puts each patient in one of six specially wired exam rooms with a special wheeled cart that has a computer, two monitors and a high-definition video camera perched on top.

There is a digital stethoscope for listening to a patient’s breathing, and additional equipment can transmit views of a patient’s ears, nose and throat. A close-up camera is also available to transmit views of skin lesions.

All of this data is sent to a doctor’s access terminal at his home or even to a tablet or laptop in any Internet-equipped location. Data encryption is used to make sure that the electronic medical data remains private.

Guss noted that the cart, with its high definition cameras, allows him to see patients with a similar level of detail that he would get standing at the bedside. But that does not mean that telemedicine is hands-off medicine. Nurses are critical in serving as a doctor’s surrogate hands.

“Let’s say you come in with a sore wrist. I’m obviously not going to be able to palpitate your wrist, but I can direct the nurse to do it and I can observe to see if it’s painful,” he said.

Because the hospital’s systems are all digital, the remote doctor can review tests, X-rays and other results after a patient’s initial examination. However, protocol still requires a doctor who is physically present at the hospital to review the remote doctor’s work before sending a patient home.

Because emergency departments operate on a triage system that takes the most severely injured patients first, Guss said only those who are well enough to wait end up being seen by a telemedicine doctor. If there are enough doctors present in the hospital to handle every problem that comes through the front door, he said, there is no reason to use telemedicine in the first place.

Guss said doctors who agree to serve on telemedicine call are paid only for the time they actually see patients. This arrangement should be cheaper than simply bringing in an extra doctor when things get busy because emergency room traffic is not perfectly predictable, he said. While it may be busy for an hour, volume may quickly reduce, leaving that extra doctor with little to do.

“What we’re trying to show in this program is that this use of telemedicine is safe and that it’s cost-effective,” he said.